Terapia sistémica con niños expuestos a violencia doméstica.

Terapia sistémica con niños expuestos a violencia doméstica.

(Systemic therapy with children who have witnessed domestic violence. )

Victoria Georgopoulou.

South London and Maudsley NHS Trust. Londres.

 

Resumen

El objetivo del presente artículo es demostrar como la teoría y terapia sistémica fueron aplicadas a madres y niños que han sufrido violencia doméstica. El trabajo terapéutico fue llevado acabo por la autora, quien es de origen griego, en un ‘Refuge’ en Londres durante los últimos tres años. ‘Refuge’ es una organización que ofrece protección y ayuda a mujeres y a sus hijos que han experimentado violencia intrafamiliar. Esta ponencia se basa también en previas investigaciones relacionadas con el tema. Algunas de las áreas que se tratan desde la perspectiva sistémica son las siguientes: . El impacto de la violencia doméstica en niños y la familia (incluyendo los casos de trastorno por estrés postraumático). . La formación de metas terapéuticas en colaboración con los niños y sus madres. . El uso de la creatividad y las ideas sistémicas aplicadas en las intervenciones realizadas teniendo en cuenta las necesidades de los niños y sus madres. . El papel que desempeñan tanto los sistemas familiares como los profesionales en las diferentes intervenciones. Los puntos anteriores se ilustrarán a través de un caso clínico. Durante las sesiones de terapia tanto las madres como los niños empezaron a darle sentido a las experiencias violentas vividas. El artículo finaliza con una discusión sobre la contribución de la terapia sistémica en el área de la violencia doméstica.



Introduction

The aim of this article is to show ways of using systemic theory and therapy in work with children who have witnessed domestic violence and their mothers. During the last three years the author, a Greek psychologist and psychotherapist, has been working therapeutically for Refuge in London. Refuge is an organisation, which offers accommodation and psychological support to women and children who have experienced domestic violence.

This article is based on the above therapeutic work (systemic approach) as well as on research in the field.

The topics include:

The impact of domestic violence on children and their families, including post traumatic stress disorder.
Therapeutic goals
Case study
Creative use of systemic ideas and examples from case study
Conclusions in relation to the contribution of systemic therapy in the field of domestic violence.

The impact of domestic violence on children and families

There is a growing literature about the impact of domestic violence on children’s lives. This literature can be used to give therapists ideas about the different contexts they need to take into consideration (e. g. family relationships, parenting skills, education, health, identity issues, community life, cultural beliefs). In addition, therapists need to have in mind the circumstances of the specific child/family they work with.

Systemic ideas on multiple perspectives point out that different family members often have different views about the impact of the violence. For example, a young child might have completely different experiences of loss and change from his older siblings. It is useful to consider a two way interaction between domestic violence and the different contexts: domestic violence can have a strong impact on many contexts of a child’s life but therapists can also become curious about how different contexts can have an impact on domestic violence. Please, see diagram 1.

 

Diagram 1: Impact of domestic violence


In addition, therapists need to acknowledge that the impact of domestic violence is evolving rather than static:

· It is mediated through a number of factors (e. g. age, gender, race etc. )
· The meaning a child attributes to violent events changes in time along with the child’s cognitive, emotional and social development
· As the meaning the child attributes to violent events changes, so does the child’s response to the events.
· Intensity of feelings and thoughts changes in time and so do family relationships
· There are primary and secondary effects of domestic violence

For some families the secondary effects of domestic violence can be equally damaging to the abuse itself. Some of the secondary effects include: abrupt transitions, interruption of friendships, educational problems, losing a sense of belonging to the local community, losing contact with the extended family and other support systems, living in communal accommodation such as refuges, financial difficulties and living with the fear of being traced by the perpetrator. It is important to address these issues, especially if family members consider them to be their main concern. Therapy can provide a safe space for family members to talk about how they can come to terms with these losses and develop new life stories.

According to Hester, Pearson and Harwin (1) there is no uniform response to living with domestic violence. Children’s responses vary enormously, with some children being affected far more than others. Children within the same family can be quite differently affected; Peled and Davis (2); Saunders (3). Each child’s experiences and reactions are unique.

It is therefore important to find out exactly what each child has experienced in order to gain some understanding of what the possible impact of these experiences might be. For many children the impact of living with domestic violence will be compounded by the impact of other types of abuse (sexual or physical abuse by the same perpetrator) and abrupt transitions.

The wide range of effects children might experience in circumstances of domestic violence can include behavioural, physical and psychological effects which may be short term or long term.

A range of personal and contextual factors can influence the extent of the impact; Kelly (4). These ‘mediating variables’ are often referred to as ‘protective’ or ‘vulnerability’ factors in that they can improve or accentuate the child’s response to the violence; Moore et al (5). These factors might include any of the following:

· Age
· Gender
· Race
· Socio-economic status
· Disability
· Mother-child relationship
· Frequency and form of violence
· Children’s coping strategies

Age as an influencing factor

Age has an influence in terms of the ways children are able to make sense of their experiences and the range of options they have to express their distress or anxiety.

Generally babies and toddlers are more likely to have physical symptoms of their anxiety such as stomach-aches, diarrhoea, asthma, sleep disturbances and in some cases delayed development:; Alessi and Hearn (6).

Babies and toddlers are particularly vulnerable for a number of reasons:

Parents might think that they are too young to understand the extent of violence.
They are usually the ones among the children who witness most of the violence since they spend most of the time with their mothers
They are at a crucial stage of development
They possess little or no means of making themselves safe and can easily get caught in violent episodes
They do not have the cognitive and language skills to ask questions and to make sense of what is happening in their family environment

Primary school children might express their fears behaviourally and emotionally; Hilberman and Munson (7). Primary school children have the language skills to ask questions and the ability to make some choices but they often feel equally powerless during a violent episode. Their education and friendships might be affected too. Home might not be a safe place to invite friends or to talk about at school, which in turn might make children feel isolated.

For teenagers who live in a violent environment there are a number of issues too. Developmentally they are at a stage when they are expected to show increasing independence (within cultural variations) and a sense of belonging to peer groups. When however they cannot have a sense of safety at home, it might be difficult for them to develop meaningful relationships, especially if they have had to move frequently due to the violence. In addition, their understanding of relationships might be skewed because of what they have witnessed at home. Owing to domestic violence some teenagers have to undertake responsibilities that are well beyond those of their peers such as a parental role towards their siblings, or becoming their mother’s partner in daily decision making.

Adolescents in the above circumstances may attempt to gain relief through drugs, early marriage or pregnancy (Mullender, 8) or they might become involved in criminal activity; Jaffe, Wolfe and Wilson (9).

 

Gender as an influencing factor

Research before 1980 concerning the role of gender on children’s ways of reacting to domestic violence tended to be characterised by an assumption that girls and boys will respond in stereotypically gendered ways. More recent research takes gender into account as a critical factor but allows for differences within as well as between the responses of girls and boys; Kelly (10). Pagelow (11) found that for boys, living with and witnessing domestic violence was related to their subsequent violent behaviour in relationships in adulthood, but that similar experiences for girls were not linked to their becoming victims as women. Kalmuss (12) found that there was a correlation between children living with domestic violence and subsequent violent behaviour in adult relationships. However this correlation was not gender specific; both boys and girls could be victims as well as perpetrators.

There are a number of gender issues that need to be explored in the context of domestic violence:

- Gender identity for children who have witnessed domestic violence.
- Being a single mother following separation from a violent partner
- Gender-specific responses from agencies and the Court
- Cultural beliefs in relation to gender and domestic violence

Race as an influencing factor

Fantuzzo and Lindquist (13) suggest that race and racism are important variables both in terms of how families responded to violence and in how agencies responded to families. Imam (14) points out that for many Black children (who live in ‘white dominated’ societies) the family home is considered a refuge from the daily hostility and racism they experience. Any violence inside the home can seriously undermine that sense of safety and can lead to feelings of vulnerability and insecurity for children. Imam (14) explains that cultural and religious expectations for Asian girls (who live in ‘white dominated’ societies) might lead to their being ostracised by their community if they try to leave with their mother to go to a refuge. The practice of using children as interpreters is inappropriate in situations of domestic violence. It can restrict the amount of information women feel able to disclose in the presence of their children, or force women to give details, from which they would like to have protected their children.

Cultural and spiritual beliefs play an important role both in the way people give meaning to their experiences and in the recovery process. The therapist can facilitate conversations about personal, family and community beliefs. The therapist often needs to decide whether to respect or to challenge cultural beliefs (including his/her own). When cultural beliefs encourage discrimination and abuse of power, it is important to challenge them in therapy. This is not an easy decision to make; our judgement of others’ cultural beliefs is bound to be influenced by our own upbringing and social context. For instance, it might be more difficult to notice and challenge a discriminatory cultural belief that has been part of our own cultural upbringing.

 

Witnessing domestic violence and post-traumatic stress disorder

In the context of domestic violence it may be particularly difficult for children to deal with traumatic events which are taking place within the family, undermining the child’s notion of safety. There is a growing body of research to suggest that children can experience PTSD in similar ways to adults and may react in such a way to witnessing violence; Pynoos and Eth (15). However, it is important to treat the concept with caution and not to apply it as some generalised pathology to all children living with domestic violence.

In addition, children’ s reactions might become apparent much later than the traumatic event and may, therefore, be difficult to link to the original trauma; Jaffe, Wolfe and Wilson (9).

Harris et al (16) summarise some of the main manifestations of PTSD in children as:

- Numbness and detachment with withdrawal
- Disturbed sleep
- Impaired concentration and memory
- Hyper-alertness
- Experiencing of ‘flashbacks’

Therapeutic goals

Given that the impact of domestic violence is evolving and that family needs change, it is important for the therapist to involve family members as much as possible in forming therapeutic goals. In addition, the therapist needs to be aware that different families have a differing sense of time. Some families might need a considerable time to elapse from the violent episodes before they can start talking about their experiences. Others find it helpful talking about these episodes shortly after they happen. It is also important to differentiate between a crisis situation and a calmer situation when family members have regained a sense of safety and stability.

Families in crisis might need to focus on issues of immediate concern and might not be willing to talk about past events or make long term plans. During a crisis situation, focusing on the strengths of the family and helping them make practical plans can be one way of empowering the family.

When thinking about therapeutic goals I often put to myself and to family members some of the following questions:

· What kinds of conversation/action are needed for the child and his/her family to start feeling safe and to gain some control over their lives?
· Which areas of the child’s life have been affected by domestic violence?
· What needs to happen in the family and in the larger professional system to prevent further damage and to start the recovery process?
· How can support systems be created or mobilised? What should the role of the therapist be in this process? What kind of support would family members find the most useful?
· What are the family’s needs at this point in time? What are the priorities of the agencies which work with the family? Is there a good enough fit between the two?
· What kind of questions would be the most useful in order to explore family relationships?
· What kind of questions or interventions are needed in order to track down transitions, loss, dangerous situations as well as new opportunities?
· What kinds of questions are needed to explore changes in family relationships?
· What kind of interventions can be used to recreate a sense of strength, belonging, togetherness and safety?

Different family members want to set for themselves different therapeutic goals. Some examples include the following:

· Increasing the child’s sense of control over the situation
· Reducing some of the long term impact of domestic violence (in terms of gender identity, academic achievements, adult intimate relationships etc. )
· Increasing the child’s ability to do well in current circumstances
· Family members coming to terms with what has happened
· Re-establishing a sense of value for oneself
· Making new friends at school
· Developing a sense of direction for the future
· Developing race and gender identity that is not restricted by experiences of domestic violence.

Case study

Mrs H. and her four children moved from Scotland to Refuge in London following ongoing verbal and physical abuse perpetrated by her husband. The violence had been witnessed by all the children (Yassin 12, Fatima 11, Mariam 7 and Salim 4) throughout the years. Following the move to Refuge, Fatima and Mariam became increasingly tearful, while Yassin, who had a learning disability, exhibited challenging behaviour. Salim, who up to that point had only used non-verbal communication, started talking. Fatima was occasionally angry with her mother for taking them away from their home and family. When the family arrived at Refuge all the children were out of school until places were made available locally. Mrs H could no longer rely on family and friends for respite care of her children and she found it challenging responding to their needs while at the same time recovering from the violence.

Mrs H welcomed onsite support for her children: groupwork, individual therapeutic sessions and leisure activities. She did not wish to join a mothers’ group but welcomed the idea of family therapy.

During individual and family therapy sessions, the children had the opportunity for the first time to talk about how they had experienced the violence. Fatima said that: “my mum was sad in the old house because my dad used to hit her every day, especially if he was drunk. Sometimes I tried to stop him”. Yassin and Mariam said that they used to cry when the violence was taking place.
Gradually the children settled into local schools and made some new friends. After ten months of sharing a room with her mother and siblings, Fatima in particular, found the stresses of communal living too difficult to handle. She could not concentrate to do her homework and she started struggling at school. She also talked about hurting herself. At that point Mrs H, despite her financial difficulties, decided to move into private accommodation.

Creative ways of using systemic ideas

Genogram or Ecogram

The genogram or ecogram can be adjusted for use in therapeutic work in relation to domestic violence. It does not have to be used at the beginning of therapy. Initially, family members might feel overwhelmed by their experiences and they might find it difficult to concentrate in the preparation of a genogram. On these occasions the therapist might leave the genogram for subsequent sessions or might suggest preparing only a small part of it, focusing mostly on issues that most closely relate to the concerns of the family.

Some of the issues that can be highlighted through the use of genograms and ecograms include the following:

· Occurrence of domestic violence across generations · Existence of support systems (friends, relatives and agencies) which helped family members while domestic violence was ongoing or which helped them escape the violence · Family, community and wider cultural beliefs in relation to violence, leaving a violent partner and receiving help · Power imbalances between family members and risks of future occurrence of violence between family members · Impact of domestic violence on family relationships

There are numerous creative ways of constructing genograms or ecograms which allow children to actively engage in the process. For instance, instead of using squares to depict men and circles to depict women, the therapist can ask the children to make pictures of the people and the agencies involved. The pictures can subsequently be cut out and placed on a big piece of paper. This way makes it possible to arrange and re-arrange the pictures to show how relationships change in time. For example, a child might place his own picture close to that of his father before a violent incident and then move it far away to show that he no longer feels emotionally close to his father.

McGoldrick (17) has developed a particularly playful way of preparing genograms with families. She asks family members to choose from a wide collection of small objects, toys and human figures the ones which best represent them and to place them on a big piece of paper. She gives people time to explain why they chose particular shapes and what these show about family relationships.

By engaging children in the process of preparing genograms/ecograms, they are given the opportunity to show how they view family relationships in the context of domestic violence. In addition, this process might allow children to start asking questions in relation to issues that are still confusing for them.

Example from case study in relation to use of genograms We spent two sessions working on the genogram. One was a family session and the other was a session with Mrs H on her own. During the family session we used art and crafts and we prepared the genogram in the shape of a palm tree (the older children chose that type of tree). Each leaf was a different family member. I asked them to show -using the leaves-how family relationships were at different points in time (in the old house when domestic violence was taking place, when they first arrived at Refuge and at the time of the session).

The visual and tactile aspect of the exercise allowed all children to participate. They shared (views) about the deterioration in the relationship between mother and daughters. They also talked about the way Yassin encouraged his mother to go back in order to give his father ‘one more chance’. Please, see diagram 2.

 

Diagram 2: Genogram én the shape of palm tree


In the genogram session with Mrs H, she talked about how she had witnessed her mother being physically abused by her father most of her childhood. She also said that her final decision to leave the family home was linked to her desire to make sure her daughters would not go through violent experiences in their own relationships.

When we explored cultural beliefs in relation to violence, Mrs H talked about feeling torn between her relatives from Yemen who do not see her as a good mother (following her move to Refuge) and her British friends who reassure her that she is doing the best for her children and herself.

In relation to receiving help Mrs H said that where she lived before she had had an extended support network (relatives, friends and respite care from social services). All of this support had disappeared when she moved to London.

In terms of the impact of domestic violence on family relationships, Mrs H. said that she no longer had a close relationship with her daughters who occasionally blame her for all the difficulties they go through.

We also talked about current power imbalances in the family and Mrs H expressed her concern that she had started hitting her daughters when they misbehaved. She said that she was worried about it and that she would like to have a session on this issue. Please, see diagram 3

 

Diagram 3: Genogram


Exploring change

Children who have been through domestic violence experiences have often been through abrupt transitions in their lives, such as leaving home, school, neighborhood, moving to Refuge or changes in family structure etc.

Therapy sessions might be the first opportunity for children and other family members to reflect on what these changes have meant for them and what they want to do next. When exploring these changes with children and other family members it is important to do so in a way that makes them more tangible for children. Time and space can be abstract dimensions for children; using pen and paper and finding ways to depict these changes visually makes conversations more interesting and meaningful to children. For instance, the therapist can encourage children to draw a “life path” along which they can show the sequence of events as they remember them. A life path or time line can also be used to depict the sequence of interactions of an important event (i. e. a violent episode). This way of working slows down the conversations to a pace that children can follow. In addition it allows mothers to find out how much their children remember and what sense they are making of past events. While the children draw the life path, the therapist can gradually ask them questions. For example, if a child draws a violent scene, the therapist can ask how the different people depicted in the scene were feeling at the time, how they reacted, what they would like to have done differently etc. Children sometimes arrive at the conclusion that changes took place because they did something wrong. This is an important issue and when appropriate it can be addressed as part of the life path exercise. Mothers have an important role to play in validating that changes were not caused by something their children did.

Another way of tracking down changes visually is by exploring the changes that took place in the family space. For example, the therapist can ask the children to draw the space that the family was using before and after the violence occurred. This exercise allows children to show through drawing and to talk about tangible changes in their everyday lives. The way we use space is closely connected to the way we relate to each other, as a result this exercise often leads to a discussion about changes in family relationships.

Example from case study in exploring changes
In my work with this family the exercise and the conversation about the life path enabled the children to clarify the order of events as well as to ask why their mother and the agencies involved had decided that the best option would be to leave the family home.

When we worked on the changes in family space, it became apparent that the transition from a four-bedroom house to one room was extremely challenging for all family members. The daily fights between the children were subsequently viewed as a normal response to a difficult situation rather than disobedience towards their mother. Family members became witnesses of each other’s losses. For example, Fatima talked about leaving behind her cat, her computer, her schoolwork, and all the furniture in her bedroom. She talked about how she missed being able to have some quiet time to think or to do her schoolwork.

‘Internalised other’ interview

The ‘internalised other’ interview is based on the idea that apart from our own feelings, beliefs and meanings we also have some understanding of those of other people, especially the ones who are close to us. The purpose of this type of interview is to bring forward our internal understanding of other people so that we can approach a certain situation from the perspective of another person.

When adults are in a violent relationship, they are not always aware of the impact of the violence on their children’s well being. Using ‘internalised other’ interviews for the parents might allow them to think and feel about the violent situations from their children’s point of view. Similarly when children experience multiple losses due to domestic violence, they may not be aware of other family members’ experiences. Using ‘internalised other’ interviews with children can help them realise that they are not the only ones experiencing loss.

The ‘internalised other’ interview takes place as follows. One family member answers questions as if they were someone else. For example, a mother might be asked to answer questions from her child’s point of view. The other family members are invited to listen in but not to contribute or interrupt while the ‘internalised other’ interview takes place. There is no recommended duration for this type of interview but it is advisable to leave time in the session to discuss the new ideas that emerge. The ‘internalised other’ interview starts with a couple of simple grounding questions whose only aim is to help the family member get used to answering as if they were someone else. All questions start with the name of the other person so that there is a constant reminder that the family member has to answer from the perspective of someone else. For example, if a mother is called Mrs H and she wants to do the interview from the perspective of her daughter Fatima, the therapist should call the mother Fatima at the beginning of every question.

Examples of initial grounding questions:

- Fatima, how old are you?
- Fatima, what is your brother’s name?
- Fatima, which school do you go to?

Following these initial questions the therapist can explore in detail issues that are important for the specific family. The ‘internalised other’ interview often brings forward new meanings and new ways of understanding other people’s views. At the end of the interview the therapist can start a different conversation engaging all family members. One way of starting this conversation is by asking the person who was interviewed how the experience has been for them and whether they have developed some new ideas.

The conversation that follows an ‘internalised other’ should not be of a debriefing style. The purpose of the conversation is not to distance the person from the role they played but to help them and other family members decide which of the new ideas they want to keep and which to leave behind. The conversation that follows can also help them think how they can change their own beliefs and meanings to make space for the new ideas that have emerged.

Example from case study in using ‘internalised other’ interview.

We did the internalised interview twice. Fatima was interviewed in the position of her mother and vice versa. While interviewed as her mother on the topic of leaving the family house and moving to Refuge, Fatima showed through her answers that she was taking into consideration the needs of the children. Mrs H confirmed this in the conversation that followed. Fatima said that she had not been aware of this aspect of her mother’s decision-making. Prior to the internalised other interview, even when she had talked to her mother on this topic, she had always believed that her mother had only thought about her own personal safety.

Mrs H in turn said that when she had had to answer questions from the position of Fatima, she realised that whenever her daughter expressed bitterness or sadness, this was not intended to be a rejection of her mother. Up to that point Mrs H had thought that Fatima should try to be content in the new circumstances interpreting any failure to do so as a rejection of her as a mother.
This way of interviewing opened up new possibilities for this mother and daughter to understand each other in the difficult context of recovering from domestic violence.

 

Letter writing

Children often feel confused when they have lived in violent family contexts. Letter writing can be used in therapy as a helpful medium for children to express personal thoughts or to ask difficult questions. For example, a child might write down all the questions that they would like to ask their parents about the violence. When it is safe the child can actually ask these questions and record the answers. Even if the child cannot ask these questions to one of the parents for safety reasons, it might still be important for the child to have them written. This exercise might act as a way of validating the child’s experience and freeing them to give their attention to other issues.

Example from case study in relation to letter writing

During a family therapy session each family member was asked to write a brief letter to an important person. This is what Fatima wrote to her mother (diagram 4).

 

Diagram 4: Letter writing

 

Alternating between meaning and action

One of the contributions of systemic thinking has been to examine the interaction between the meaning we attach to certain situations and the action that follows. By the same token the action we choose influences the new meanings that we develop.

Example from case study; alternating between meaning and action

Please see diagrams 5 and 6.

 

Diagram 5



Diagram 6: alternating between meaning and action

Working with the larger family and professional systems

When domestic violence has taken place, it is important to work in collaboration with other professionals and agencies. This is because the impact of domestic violence is more likely to spread across a number of contexts (education, health, mental health, housing etc. ) and generations.

Collaborating with professionals from the above contexts can prove useful for all the people involved. The child’s recovery process can be greatly facilitated when professionals set up appropriate support systems so that they can provide a co-ordinated response to the child’s needs.

Therapists have an important role in mapping the larger family and professional system. When going through a crisis (e. g. domestic violence and its aftermath) families often have to deal with many professionals at the same time. Mapping the system can help family members have a better sense of each agency’s role and expectations as well as their own expectations from agencies.

Different families have different beliefs about and experiences of receiving help. Exploring these beliefs can give family members and professionals some ideas about how to work together. In addition, different agencies have different agendas, priorities, human and financial resources. It is worth exploring whether there is a good fit between family and agency beliefs.

Final connections: contribution of systemic ideas in the field of domestic violence

· Domestic violence manifests as a result of interactions in a specific family and wider societal practices and beliefs (e. g. in relation to gender, race, class, ability). Systemic ideas can contribute by allowing practitioners to explore issues at individual as well as contextual levels such as family, extended support network, community, etc.

· Systemic theories talk about the ‘both/and’ approach. This can be particularly helpful for a highly tense and often polarised topic such as domestic violence which is often approached in an ‘either/or’ way.

· Systemic theories bring the idea of ‘multiversa’ or multiple perspectives. This idea can be particularly useful in allowing different family members and professionals to share their experiences from their particular points of view.

· Systemic ideas in relation to power issues have evolved incorporating critiques from the feminist movement. Exploring power issues has gradually become an important part of therapy. Power issues need to be addressed when working with people who have been involved in domestic violence.

· Systemic theories and practices have highlighted the role of the observer/family therapist as one that has an impact on the system observed. Greater sensitivity about our role as therapists brings into the foreground personal, professional and organisational beliefs and practices. Therapists who work with power and domestic violence issues often have to consider their own values as well as those of their agencies.

References

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2. Peled E, David D. Groupwork with children of battered women: a practitioner’s manual. Thousand Oaks: Sage; 1995.

3. Saunders A, Epstein C, Keep G, Debbonaire T. It hurts me too: children’s experiences of domestic violence and refuge life. Bristol: WAFE/ Childline/NISW; 1995.

4. Kelly L. When woman protection is the best kind of child protection: children, domestic violence and child abuse. Administration 1996; 44 (2): 118-135.

5. Moore JG, Galcius A, Pettican K. Emotional risk to children caught in violent marital conflict- the Basildon treatment project. Child abuse and neglect 1981; 5: 147-152.

6. Alessi JJ, Hearn K. Group treatment of children in shelters for battered women. In Roberts AR, editor. Battered women and their families. New York: Springer; 1984.

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8. Mullender A. Children living with domestic violence. Adoption and fostering 1996; 20(1) : 8- 15.

9. Jaffe P, Wolfe DA, Wilson SK. Children of battered women. California: Sage; 1990.

10. Kelly L. The interconnectedness of domestic violence and child abuse: challenges for research, policy and practice. In: Mullender A, Morley R, editors. Children living with domestic violence. London: Whiting and Birch; 1994.

11. Pagelow MD. Factors affecting women’s decisions to leave violent relationships. Journal of family issues 1981; 2: 391- 414.

12. Kalmuss D. The intergenerational transmission of marital aggression. Journal of marriage and family 1984; 46: 11-19.

13. Fantuzzo JW, Lindquist CU. The effects of observing conjugal violence on children: a review and analysis of research methodology. Journal of family violence 1989; 4 (1): 77- 94.

14. Imam UF. Asian children and domestic violence. In Mullender A, Morley R, editors. Children living with domestic violence. London: Whiting and Birch; 1994.

15. Pynoos RS, Eth S. Children traumatised by witnessing acts of personal violence; homicide, rape or suicide behaviour. In: Eth S, Pynoos RS, editors. Post traumatic stress disorder in children. Washington: APA; 1985.

16. Harris HJ, Black D, Kaplan T. When father kills mother; guiding children through trauma and grief. London: Routledge; 1993.

17. McGoldrick M, Gerson R. Genograms in family assessment. New York: W. W. Norton; 1985.

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